Concept of Iatrogenic disease
Iatrogenic harm ranks as the sixth highest public health problem in the developed world, worldwide accounting for as many as 10,000 deaths each and every day (cf. 8,000 HIV/AIDS; 3,000 road traffic accidents).
Perceptions of risk, and of what constitutes an appropriate degree of safety, vary considerably—and this depends also on the context. Think of these in terms of the patient related risks e.g., surgery on a patient with heart failure, investigation- or treatment-related risks, and individual healthcare practitioner and healthcare system risks.
Acceptability of risk in health relates to a balance between the potential for harm; the likelihood of doing good; and the choices available at the time. That is, the doctor and the patient together are always having to weigh up the. risks and benefits of any option (and comparing them to other options).
Adverse outcomes in medicine
Medical records suggest that approximately 10% of admissions to acute care hospitals are associated with an adverse event; some half of these are the cause of admission and the other half occur during the index admission. One in 100 GP encounters involves an adverse event. Prior to 2000, the US, UK, and Australia each spent about $1 a week per person (5% of their Healthcare budget) on treating adverse events, and another 5% in indirect costs—loss earnings, ongoing care, and including 1-2% on the tort system.
System failure v individual failure
The ‘Swiss Cheese” model of error prevention assumes that a large number of checks and balances (the cheese slices) in place to prevent errors, but each of them is imperfect (the holes in the slices)—it usually takes a number of system failures for an adverse outcome to occur. But, in fact, inadequate staffing, overwork, faulty procedures can (and sometimes do) align to produce errors.
Considerations include:
- How to collect and/or assess necessary information and how various components interrelate
- How to respond appropriately to things that go wrong
- How to develop/apply effective strategies for preventing similar problems in the future—i.e., error tolerant systems within which operate collective effort of individual HCPs and patients. It is a truism that substantial advances made in healthcare lie mainly in changes driven and maintained by individuals.
“Cost” of health care–State/National Models for Funding HealthCare
What percentage of state funding is ideal? This depends on perceptions of social responsibility and efficiency. Most countries have a mixture of:
- Fee for Service
- Capitation
- Full state funding
- Insurance-funded Managed Care
Australia’s Universal Health Care (Medicare) System with high quality outcomes and GP as ‘gatekeeper’; allows for additional payment for special services. (cf. UK ~ except payment by capitation; US expensive Managed care system; Malaysia employer-based clinics). One way of allocating resources is by ranking healthcare interventions according to their cost per quality adjusted life year (QALY) – evaluating cost-effectiveness of medical treatment in defined group of patients e.g., PBS drugs. Consider QALY and the cost of some of the procedures used in medicine: Nevertheless, growing interest in securing more efficient allocation of resources between interventions that affect human health – evidence emerging that enormous disparities in cost per life-year saved and cost per death averted across interventions.
Hospital/ Organisation
Funding is now based on some measure of activity, such as the number of conditions managed, or interventions undertaken—these “Diagnostic-Related Groups” (DRGs) are coded on discharge/death for some 10,000 International Classification of Disease (ICD) codes.
Diagnostic-Related Groups (DRGs): Provide clinically meaningful way of relating number and type of patients treated in a hospital (that is, its Casemix) to the resources required by the hospital. Each DRG represents class of patients with similar conditions (based on ICD-10) requiring similar hospital services – important factors include principal diagnoses, procedure/s, length of stay, cost weights
The ICD-10 classification
A disease classification based on WHO’s publication A new Australian classification of procedures based on the Medicare Benefits Schedule (MBS), sometimes referred to as MBS-Extended, and Australian Coding Standards for the selection of disease and procedure codes.
Spend $1M to improve health outcomes and see that will not make much difference overall. Try $2m – result the same. What if $20M? – Even this unlikely to have a major positive benefit. Spending more does not necessarily improve outcomes for patients e.g. US spend 3 x NZ on healthcare but has higher infant mortality: appropriateness; efficiency; distribution between public health and primary, secondary, and tertiary care.
Consider also the role of allied health care and community services (HACC) etc.
Case study: Obesity in Indigenous Community
Consider statistics for overweightness and obesity among Aboriginal Australians: Aborigines have an increasing incidence of obesity and type II DM, for multiple reasons. Colonisation and aboriginal history had a profound effect on (Aboriginal) community health and uptake of health services and it is this particular history and set of circumstances that makes Aboriginal Health different from other groups. It has often been claimed in Australia that Aboriginal people have higher rates of diabetes because they freely choose bad Western foods, such as potato chips, soft drinks and alcohol, for which they are genetically not “programmed.” Thus their health problems read as the following: they (self) choose poor foods for which their bodies are genetically not capable processing Western food (biology) and they (self) are lazy or indifferent about their health (culture). The conclusion, which policy makers informed by this approach reach, is that it is the Aborigine’s problem that they are sicker and die sooner, and that there is little or indeed nothing that can be done about it. A sociological account, conversely, directs attention to the political and economic shaping of lifestyles available to subordinate populations, and to the way in which racism systematically destroys the beneficial aspects of an indigenous population’s culture. There is a profound need for health care interventions to be tailored for specific populations and cultural settings – and strong arguments for members of Aboriginal communities being accorded lead roles in the provision, delivery and shaping of health care strategies to Aboriginal patients.
